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Madonna Manor

Details

Type of Ownership Non profit - Corporation
Participates in Medicare? Yes
Participates in Medicaid? Yes
Certified Beds 60
Continuing Care? No
Resident Council? Yes
Family Council? No
Multi-Home Chain? No
Located in a Hospital? No
Special Focus Facility? No

View:    Health Inspections  |  Quality Measures  |  Staffing  |  Fire Inspections

Health Inspections  

Most Recent Inspection: 04/06/2011

Date of last standard health inspection: 04/06/2011
Quality Indicator Survey No
Dates of Complaint Investigations: 04/01/2011 - 03/31/2012
Total number of Health Deficiencies for this nursing home: 0
Average number of Health Deficiencies in KY: 3
Average number of Health Deficiencies in US: 3
Range of Health Deficiencies in KY: 0 - 8

Inspection, 00/04/2011

Mistreatment Deficiencies
Deficiency Inspection Date Correction Date Level of Harm Residents Affected
1) Hire only people with no legal history of abusing 00/04/2011 01/06/2011 neglect or mistreatment of residents. neglecting or mistreating residents; or 2) report

Inspection, 03/00/2009

Resident Rights Deficiencies
Deficiency Inspection Date Correction Date Level of Harm Residents Affected
Keep residents' personal and medical records private and confidential. 03/00/2009 01/08/2010 1 Some

Inspection, 00/07/2009

Resident Rights Deficiencies
Deficiency Inspection Date Correction Date Level of Harm Residents Affected
Keep residents' personal and medical records private and confidential. 00/07/2009 01/04/2009 2 Few

Inspection, 00/05/2008

Administration Deficiencies
Deficiency Inspection Date Correction Date Level of Harm Residents Affected
Post nurse staffing information/data on a daily basis. 00/05/2008 02/00/2009 2 Few
Make sure that the facility is administered in an acceptable way that maintains the well-being of each resident. 00/05/2008 02/00/2009 4 Some
Employ staff that are licensed 00/05/2008 02/00/2009 or registered in accordance with state laws. certified
Choose a doctor to serve as the medical director to create resident care policies and coordinate medical care in the facility. 00/05/2008 02/00/2009 2 Many
Quickly tell the resident's doctor the results of laboratory tests. 00/05/2008 02/00/2009 2 Few
Keep accurate 00/05/2008 01/06/2011 Some complete and organized clinical records on each re
Train all employees on what to do in an emergency 00/05/2008 02/00/2009 Many and carry out unannounced staff drills.
Set up an ongoing quality assessment and assurance group to review quality deficiencies quarterly 00/05/2008 01/06/2011 Some and develop corrective plans of action.
Environmental Deficiencies
Deficiency Inspection Date Correction Date Level of Harm Residents Affected
Ensure that a nursing home area is free from accident hazards and provide adequate supervision to prevent avoidable accidents. 00/05/2008 01/06/2011 3 Few
Have a program that investigates 00/05/2008 02/00/2009 Some controls and keeps infection from spreading.
Mistreatment Deficiencies
Deficiency Inspection Date Correction Date Level of Harm Residents Affected
Keep each resident free from physical restraints 00/05/2008 02/00/2009 Few unless needed for medical treatment.
Nutrition and Dietary Deficiencies
Deficiency Inspection Date Correction Date Level of Harm Residents Affected
Store 00/05/2008 02/00/2009 and serve food in a safe and clean way. cook
Pharmacy Service Deficiencies
Deficiency Inspection Date Correction Date Level of Harm Residents Affected
Ensure that residents are safe from serious medication errors. 00/05/2008 02/00/2009 2 Few
Provide routine and emergency drugs through a licensed pharmacist and only under the general supervision of a licensed nurse. 00/05/2008 02/00/2009 2 Many
Quality Care Deficiencies
Deficiency Inspection Date Correction Date Level of Harm Residents Affected
Provide activities to meet the interests and needs of each resident. 00/05/2008 02/00/2009 2 Many
Ensure services provided by the nursing facility meet professional standards of quality. 00/05/2008 01/06/2011 2 Many
Provide care by qualified persons according to each resident's written plan of care. 00/05/2008 01/06/2011 2 Few
Provide necessary care and services to maintain or improve the highest well being of each resident. 00/05/2008 01/06/2011 2 Few
Make sure that residents receive treatments/services to maintain or improve their ability to care for themselves. 00/05/2008 02/00/2009 3 Few
Give residents proper treatment to prevent new bed (pressure) sores or heal existing bed sores. 00/05/2008 02/00/2009 3 Few
Ensure residents maintain acceptable nutritional status. 00/05/2008 02/00/2009 2 Some
Resident Assessment Deficiencies
Deficiency Inspection Date Correction Date Level of Harm Residents Affected
Assess in a timely manner the resident when the resident enters the nursing home. 00/05/2008 02/00/2009 2 Many
Develop a complete care plan that meets all the resident's needs 00/05/2008 02/00/2009 Few with timetables and actions that can be measured.
Allow residents the right to participate in the planning or revision of care and treatment. 00/05/2008 02/00/2009 3 Few
Resident Rights Deficiencies
Deficiency Inspection Date Correction Date Level of Harm Residents Affected
Immediately tell the resident 00/05/2008 01/06/2011 and a family member of situations (injury/decline/ the resident's doctor

Inspection, 02/08/2006

Environmental Deficiencies
Deficiency Inspection Date Correction Date Level of Harm Residents Affected
Ensure that a nursing home area is free from accident hazards and provide adequate supervision to prevent avoidable accidents. 02/08/2006 00/02/2007 3 Few
Quality Care Deficiencies
Deficiency Inspection Date Correction Date Level of Harm Residents Affected
Provide care by qualified persons according to each resident's written plan of care. 02/08/2006 00/02/2007 3 Few

Inspection, 02/04/2005

Pharmacy Service Deficiencies
Deficiency Inspection Date Correction Date Level of Harm Residents Affected
Maintain drug records and properly mark/label drugs and other similar products according to accepted professional standards. 02/04/2005 03/00/2006 2 Few

Inspection, 02/02/2004

Environmental Deficiencies
Deficiency Inspection Date Correction Date Level of Harm Residents Affected
Maintain comfortable and safe temperature levels. 02/02/2004 02/08/2005 2 Some
Mistreatment Deficiencies
Deficiency Inspection Date Correction Date Level of Harm Residents Affected
1) Hire only people with no legal history of abusing, neglecting or mistreating residents; or 2) report and investigate any acts or reports of abuse, neglect or mistreatment of residents. 02/02/2004 00/06/2005 2 Few
1) Hire only people with no legal history of abusing 02/02/2004 00/06/2005 neglect or mistreatment of residents. neglecting or mistreating residents; or 2) report
Quality Care Deficiencies
Deficiency Inspection Date Correction Date Level of Harm Residents Affected
Ensure services provided by the nursing facility meet professional standards of quality. 02/02/2004 02/08/2005 2 Few
Make sure that each residents' abilities in activities of daily living do not decline, unless unavoidable. 02/02/2004 00/06/2005 2 Few
Ensure that residents with limited range of motion receive appropriate treatment and services to increase range of motion or prevent further decrease in range of motion. 02/02/2004 01/01/2005 2 Some
Resident Rights Deficiencies
Deficiency Inspection Date Correction Date Level of Harm Residents Affected
Provide care for residents in a way that maintains or improves their dignity and respect in full recognition of their individuality. 02/02/2004 02/08/2005 2 Some
Provide care for residents in a way that maintains or improves their dignity and respect in full recognition of their individuality. 02/02/2004 02/08/2005 2 Some

Inspection, 00/06/2004

Administration Deficiencies
Deficiency Inspection Date Correction Date Level of Harm Residents Affected
Keep accurate, complete and organized clinical records on each resident that meet professional standards. 00/06/2004 00/09/2005 2 Few
Set up an ongoing quality assessment and assurance group to review quality deficiencies quarterly, and develop corrective plans of action. 00/06/2004 00/09/2005 2 Few
Mistreatment Deficiencies
Deficiency Inspection Date Correction Date Level of Harm Residents Affected
1) Hire only people with no legal history of abusing, neglecting or mistreating residents; or 2) report and investigate any acts or reports of abuse, neglect or mistreatment of residents. 00/06/2004 00/09/2005 2 Few
Develop and implement policies for 1) screening and training employees; and the 2) prevention, identification, investigation, and reporting of any abuse, neglect, mistreatment and misappropriation of property. 00/06/2004 00/09/2005 2 Few
Develop and implement policies for 1) screening and training employees; and the 2) prevention 00/06/2004 00/09/2005 investigation identification
Nutrition and Dietary Deficiencies
Deficiency Inspection Date Correction Date Level of Harm Residents Affected
Store, cook, and serve food in a safe and clean way. 00/06/2004 00/09/2005 2 Many

Inspection, 01/09/2003

Mistreatment Deficiencies
Deficiency Inspection Date Correction Date Level of Harm Residents Affected
Develop and implement policies for 1) screening and training employees; and the 2) prevention 01/09/2003 00/06/2004 investigation identification

Inspection, 01/05/2002

Environmental Deficiencies
Deficiency Inspection Date Correction Date Level of Harm Residents Affected
Ensure that a nursing home area is free from accident hazards and provide adequate supervision to prevent avoidable accidents. 01/05/2002 01/06/2002 3 Few
Quality Care Deficiencies
Deficiency Inspection Date Correction Date Level of Harm Residents Affected
Provide care by qualified persons according to each resident's written plan of care. 01/05/2002 01/06/2002 3 Few
Resident Rights Deficiencies
Deficiency Inspection Date Correction Date Level of Harm Residents Affected
Immediately tell the resident 01/05/2002 01/06/2002 and a family member of situations (injury/decline/ the resident's doctor

Nursing Home Staffing  

Information comes from data that the nursing home reports to its state agency. It contains the nursing home staffing hours for a two-week period prior to the time of the state inspection. CMS receives this data and converts it into the number of staff hours per resident per day.

National Average Average in KY Golden Living Center, Asheville
RN Staff Only1 N/A N/A 3 out of 5 stars
Total Number of Residents 86 80 54
Total, Licensed Nurse Staff Hours
per Resident per Day
16 hours 51 minutes 17 hours 42 minutes 1 hour 37 minutes
RN Hours
per Resident per Day
16 hours 3 minutes 16 hours 49 minutes 37 minutes
LPN/LVN Hours
per Resident per Day
16 hours 17 minutes 17 hours 1 hour
CNA Hours
per Resident per Day
17 hours 46 minutes 18 hours 35 minutes 3 hours 4 minutes

1 The star rating a nursing home received for the information it provided about its Registered Nurse (RN) staffing. RNs have between 2 and 6 years of education.

Quality Measures  

Information comes from data that the nursing home reports to its state agency. It contains the nursing home staffing hours for a two-week period prior to the time of the state inspection. CMS receives this data and converts it into the number of staff hours per resident per day.

Long-Term Residents

Short-Term Residents

Fire Safety Inspections

Lists the fire safety requirements that the nursing home failed to meet. Fire safety results are not included in the nursing home's Overall Rating.

Most Recent Inspection: 04/05/2011

Automatic Sprinkler Systems in all required areas Yes
Date of last standard fire safety inspection: 04/05/2011
Dates of Complaint Investigations: 04/01/2011 - 03/31/2012
Total number of Fire Safety Deficiencies for this nursing home: 0
Average number of Fire Safety Deficiencies in KY: 0
Average number of Fire Safety Deficiencies in US: 2
Range of Fire Safety Deficiencies in KY: 0 - 0

Inspection, 02/03/2005

Automatic Sprinkler Systems Deficiencies
Deficiency Inspection Date Correction Date Level of Harm Residents Affected
Automatic sprinkler systems that have been maintained in working order. 02/03/2005 03/00/2006 2 Many
Electrical Deficiencies
Deficiency Inspection Date Correction Date Level of Harm Residents Affected
Properly installed electrical wiring and equipment. 02/03/2005 03/00/2006 2 Few
Fire Alarm Systems Deficiencies
Deficiency Inspection Date Correction Date Level of Harm Residents Affected
An approved installation, maintenance and testing program for fire alarm systems. 02/03/2005 03/00/2006 2 Many
Furnishings and Decorations Deficiencies
Deficiency Inspection Date Correction Date Level of Harm Residents Affected
Restrictions on the use of highly flammable decorations. 02/03/2005 03/00/2006 2 Some
Smoke Compartmentation and Control Deficiencies
Deficiency Inspection Date Correction Date Level of Harm Residents Affected
Walls that prevent smoke from passing through and would resist fire for at least one hour. 02/03/2005 03/00/2006 2 Many

Inspection, 02/01/2004

Building Service Equipment Deficiencies
Deficiency Inspection Date Correction Date Level of Harm Residents Affected
Restrictions on the use of portable space heaters. 02/01/2004 03/00/2004 2 Few
Corridor Walls and Doors Deficiencies
Deficiency Inspection Date Correction Date Level of Harm Residents Affected
Signs that state that exit doors are to be kept closed. 02/01/2004 02/08/2005 2 Some
Electrical Deficiencies
Deficiency Inspection Date Correction Date Level of Harm Residents Affected
Weekly inspections and monthly testing of generators. 02/01/2004 02/08/2005 2 Some
Emergency Plans and Fire Drills Deficiencies
Deficiency Inspection Date Correction Date Level of Harm Residents Affected
A written emergency evacuation plan. 02/01/2004 02/08/2005 2 Many
Record of quarterly fire drills for each shift under varying conditions. 02/01/2004 03/01/2005 2 Many
Furnishings and Decorations Deficiencies
Deficiency Inspection Date Correction Date Level of Harm Residents Affected
Restrictions on the use of flammable curtains. 02/01/2004 03/00/2004 2 Some

Inspection, 00/05/2004

Miscellaneous Deficiencies
Deficiency Inspection Date Correction Date Level of Harm Residents Affected
Other fire safety features required by fire safety codes. 00/05/2004 00/09/2005 2 Many
 

2344 Amsterdam Road
Villa Hills, KY 41017

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